This workstream aimed to: 

1. Support local systems in embedding and developing social prescribing, care coordinator and health and wellbeing coach roles effectively, ensuring personalised care approaches are integrated into service delivery and strengthening the infrastructure needed for long-term sustainability and impact
2. Provide tailored support for the London personalised care workforce by developing resources, sharing key learning and insights through webinars and events, hosting a peer support forum, developing practical tools and guidance, and facilitating access to relevant training opportunities
3. Build leaders and networks across London who can champion and develop social prescribing, care coordination and health and wellbeing coaching across all levels of the system

Key impacts and achievements 

• Trained 12 Social Prescribing link workers, Care Coordinators and Health and Wellbeing Coaches in Action Learning Set facilitation to enable them to lead peer support in their areas 
• Supporting development of social prescribing managers as leaders, by convening them to network, share best practice and develop their teams through peer support 
• Enabled PCN managers and ICBs to set up the proper infrastructure for personalised care roles through webinars, workshops and the PCN toolkit for embedding the roles 
• Increased understanding of the personalised care roles through development of guidance including one-page descriptions of the roles, YouTube videos, newsletters and case studies 
• Facilitated the solving of challenges across London through individual ICB support, 1:1s with managers and PCN leads as well as working with NHS England and NASP to influence policy and guidance 
• Supported development of connector roles in Tower Hamlets by undertaking an in-depth review and developing recommendations 
• The Social Prescribing Innovators Programme was nominated for the NALW LinkWorkerDay23 Social Prescribing Supplier of the Year Award in April 2023
• 12 project teams including SP teams across London received Quality Improvement and evaluation training, coaching and support, as well as a share of £120,000 in funding to find innovative solutions to local challenges to social prescribing – enabled services to co-produce for the first time, innovatively engage patients, and embed improvements using newfound insights. This allowed services to lead meaningful improvement projects, improving access and experience for patients
• The team published an Innovators Toolkit to guide through the approach, process and learnings from the 2022/23 SPIP: 
  • A project in Barking & Dagenham estimated up to £16K in cost savings as a result of reduced GP appointments through providing support to local residents at community pop-up clinics
  • A project in Lambeth reduced waiting times for patients to meet for the first time with a Link Worker at the busiest practices across the borough, raised awareness among patients and allowed them to be signposted to community-based support faster. The project spearheaded collaboration and co-design with clinical colleagues and community organisations
• Key findings from the SPIP UCL evaluation: 
  • Social prescribing services became more impactful on health and wellbeing, as services became targeted to local needs
  • Social prescribing reached more people, particularly those from minority backgrounds, through outreach and more referrals
  • Trust increased between GPs and Social prescribing services, VCSE and communities, services co-produced for the first time
  • Residents had more trust in health care, had higher activation levels and felt more equipped to manage their health conditions
  • Social prescribing link workers became leaders, moving beyond crisis management to meaningful improvement, and could influence the health care system to better address local need and reduce inequality

Why was this work important?

Social Prescribing Link Workers, Health and Wellbeing Coaches and Care Coordinators were introduced to primary care by the PCN DES contract, alongside attached ARRs (Additional Roles Reimbursement scheme) funding for salaries. These roles are non-clinical and represent the first wave of a new way of working in primary care, addressing the social determinants of health and working from a biopsychosocial model of health and care.  

To support this new way of working, proper induction, training, development, management and supervision is needed. In addition, a well thought out approach to how these roles: 

• work with patients, both reactively and proactively
• work with the clinical team
• and work alongside each other

Guidance around this is available, but regional support was needed to implement successfully within a local context and to help develop the infrastructure, share best practice and challenge an old way of working within primary care.  

A core challenge has been the misuse of these roles, or lack of proper induction, support and training. The work of the team has been critical in clarifying good practice and supporting each London ICB to embed to the structures needed for these roles to have an impact. 

Partnerships, networks and funding 

The Community Led Prevention Team formed a network for Social Prescribing Managers across London, which is a regular space for managers to build connections, problem solve together and inform regional and national work. The network has around 70 members from across London, who meet on a 6-weekly basis via Teams. The team have worked closely with this network on a number of projects, such as the Social Prescribing Innovators Programme and Action Learning Set facilitation.  
 
The team has worked in partnership with Integrated Care Boards (ICBs) and training hubs to support the embedding and development of these roles. This has included providing tailored advice and guidance, sharing best practice models and insights from other areas to support local development of service and to help standardise these roles across the system. 
 
We have also worked in partnership with NHS England to share the latest guidance, strategic developments, and policy changes. This has ensured that local implementation aligns with national priorities and best practice. This partnership enabled the team to share insights and challenges from the workforce, helping to shape and influence national policies and frameworks. This includes the Workforce Development Frameworks, guidance around proactive social prescribing and more.  

Main projects and outputs   

The Community Led Prevention Team have delivered projects to provide support for the London personalised care workforce, their managers, and to promote leadership. This is two-fold, first by directly supporting front line Social Prescribing link workers, Health and Wellbeing Coaches, Care Coordinators, and secondly supporting managers and those responsible for embedding the roles to build in the proper support, training and work, the roles should have access to.  

Key Projects

• Social prescribing Innovators Programme – 12 improvement projects across London led by social prescribing link workers
• Social Prescribing Innovators Toolkit – how to create your own Innovators Programme
• Social prescribing and system support newsletters including all the latest guidance, resources, events and trainings for the roles, managers and those embedding the roles
• Action Learning Facilitator Training – in partnership with NHS London Leadership Academy we trained twelve of the personalised care roles across London to be able to run action learning sets and their own peer support
• Peer learning series – webinars and trainings to support social prescribing link workers to develop skills to work with patients and the system e.g. social prescribing for cancer, working with refugees and asylum seekers
• System Support Webinar series – a series of webinars to support people to embed the personalised care roles, e.g. how to evaluate services, supporting induction, recruitment and proper use of the roles
• Social Prescribing managers network – a regular space for managers to build connections, problem solve together and inform regional and national work
• Developing peer support across London – developing resources, case studies and working with places to develop their own peer support networks
• Case studies of how the roles are working, resources to support understanding and embedding of the roles including one-page descriptions, policy summaries, webinars, workshops and more
• 1:1 support with PCN managers and social prescribing managers to support with retention, embedding and cross working between personalised care roles
• PCN toolkit for embedding the roles and tackling health inequalities
• Proactive social prescribing workshops tailored to ICBs and boroughs
• Review of Social Prescribing and Connector Services in Tower Hamlets

What have been the common challenges? 

• Recruitment and retention – Reliance on the Additional Roles Reimbursement Scheme (ARRS) often means short-term contracts and funding uncertainties, making it difficult to build and retain a stable workforce
• Challenges of culture change to the system – These roles offer a different way of working to the medical model. The system must evolve to embed these roles and evolve multidisciplinary teams to include non-clinical issues and roles, in order to best support patients
• Referral inefficiencies – Lack of awareness of the workforce roles and their remit among healthcare professionals often results in inappropriate referrals and misaligned expectations
• Systemic barriers and increasing complexity of patients– High deprivation areas face greater challenges, with 40% of clients affected by food and fuel poverty. Long housing support wait times and the uneven distribution of social prescribers across boroughs results in areas of high need being underserved
• High workloads and burnout – Due to the issues above and increasing demand for support, the workforce often manages caseloads exceeding recommended limits. In some cases, appointment times are also insufficient, this overwhelming demand leads to burnout, high turnover rates and difficulties in retaining a skilled workforce
• Partnership working – Social prescribing requires partnership working between health, voluntary sector and often local authority, this requires structures and good relationships to be able to build effective services
• Lack of data and evidence – Insufficient infrastructure for measuring impact weakens advocacy for investment and service improvement

Resources

Key external resources 

PCN DES Contract 

Workforce Development Framework for Social Prescribing Link Workers  

Workforce Development Framework for Care Co-ordinators 

Workforce Development Framework for H&WB Coaches 

Full list of resources for Workforce and System Support workstream